Allure Of Knox County

F 0697

Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to assess the pain of a resident who received scheduled medication to control pain for one resident (Resident R4) of three residents reviewed for pain. The Facility's undated Pain Management policy documents The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. Monitoring, Reassessment and Care Plan Revision a. Facility staff will reassess resident's pain management at established intervals for effectiveness and/or adverse consequences such as: i. tolerance 11. Physical dependence iii. increased sensitivity to pains iv. constipation v. nausea, vomiting, and dry mouth vi. sleepiness, dizziness, and/or confusion vii. depression viii. itching and sweating; b. If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. c. if the pain has resolved or there is no longer an indication for pain medication, the interdisciplinary team will work to discontinue or taper (as needed to prevent withdrawal symptoms) analgesic's. d. If a resident reports or there are signs of increased pain, the facility should evaluate whether there is a time or day pattern to ensure that the problem is not due drug diversion.Resident R4's Medical Record documents that she was admitted to

the facility on [DATE REDACTED] with diagnosis to include but not limited to left below the knee amputation, spinal stenosis, anxiety and depression. On 8/27/25 at 10:50 AM Resident R4 was alert and answered questions appropriately. Resident R4 was lying bed, appeared pale, her hairline was damp and she seemed to be breathing rapidly. Resident R4 stated she was in pain, stated The nurse knows, she hasn't brought my morning medicine yet.

Sometimes it takes these agency nurses longer.Resident R4's Physician Order Sheet dated August 2025 documents Resident R4 receives the following scheduled medications for pain: Hydrocodone (narcotic) 5-325 mg, pregabalin (for pain) 75 mg and Tizanidine (muscle relaxer) 2 mg.Resident R4's Medical Record does not contain any documentation prior to or after the administration of her scheduled pain medications. On 8/29/25 at 9:00 AM V2 (Director of Nursing) confirmed that Resident R4's pain was not assessed prior to or after the administration of Resident R4's scheduled medications for pain. It (pain scale) is not on there and it should be.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Allure of Knox County

280 East Losey Street Galesburg, IL 61401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

medications were given by V5 (RN) at 10:44 AM. Neither date (8/11/25 or 8/18/25) document Resident R4's scheduled 12:00 PM dose of Pregabalin as given. Resident R4's Medical Record did not contain any documentation regarding why Resident R4's medications were not given at the scheduled time or what Resident R4's conditions was on 8/11/25 or 8/18/25.On 8/29/25 at 9:40 AM V5 (RN) stated One of two things happened, either (Resident R4) slept in and I gave the medications late, or I gave (Resident R4)'s medications on time but just did not sign them out until later. V5 stated she did not remember specifically. V5 confirmed that there was no documentation as to which possible reason was what occurred on either date. V5 stated that she did not notify the doctor or any other staff member of what occurred. I might have passed it on verbally to the next shift, I'm not sure. V5 (RN) stated that if she gave Resident R4's Pregabalin late for the 8:00 AM dose she would have waited on giving the scheduled 12:00 PM dose until 1:30 PM or 2:00 PM she wasn't sure. V5 confirmed there is no way of telling based on the documentation in Resident R4's medical record what happened on either day.On 8/29/25 at 10:15 AM Dr. [NAME] did acknowledge that she had chronic pain and that it was usually controlled with her scheduled medications as far as he knew.

Event ID:

Facility ID:

If continuation sheet